PHIMOSIS.

Phimosis
An erect penis with a case of phimosis
ICD-10	N47
ICD-9	605
DiseasesDB	10019
eMedicine	emerg/423
MeSH	D010688

Phimosis (/fɪˈmoʊsɨs/ or /faɪˈmoʊsɨs/^[1][2]), from the Greek phimos (φῑμός ["muzzle"]), is a condition in males where the foreskin cannot be fully retracted over the glans penis. The term may also refer to clitoral phimosis in women, whereby the clitoral hood cannot be retracted, limiting exposure of the glans clitoridis.^[3]
At birth, the foreskin is fused to the glans and is not retractable. Huntley et al. state that "non-retractability can be considered normal for males up to and including adolescence."^[4]
Normal developmental non-retractability does not cause any problems. Phimosis is deemed pathological when it causes problems, such as difficulty urinating or performing common sexual functions. There are numerous causes of so-called pathological phimosis. Common treatments include steroid creams, manual stretching, changing masturbation habits, preputioplasty, and circumcision.

Normal development

At birth, the inner layer of the foreskin is sealed to the glans penis. This attachment forms "early in fetal development and provide[s] a protective cocoon for the delicate developing glans."^[5] The foreskin is usually non-retractable in infancy and early childhood.^[5]
Medical associations advise not to retract the foreskin of an infant, in order to prevent scarring.^[6][7] Some argue that non-retractability may "be considered normal for males up to and including adolescence."^[8][4] Hill states that full retractability of the foreskin may not be achieved until late childhood or early adulthood.^[9] A Danish survey found that the mean age of first foreskin retraction is 10.4 years.^[10]
Rickwood, as well as other authors, has suggested that true phimosis is over-diagnosed due to failure to distinguish between normal developmental non-retractability and a pathological condition.^[11][12][13] Some authors use the terms "physiologic" and "pathologic" to distinguish between these types of phimosis;^[14] others use the term "non-retractile foreskin" to distinguish this developmental condition from pathologic phimosis.^[11]
In some cases a cause may not be clear, or it may be difficult to distinguish physiological phimosis from pathological if an infant appears to be in pain with urination or has obvious ballooning of the foreskin with urination or apparent discomfort. However, ballooning does not indicate urinary obstruction.^[15]

Cause

There are three mechanical conditions that prevent foreskin retraction:

1. The tip of the foreskin is too narrow to pass over the glans penis. This is normal in children and adolescents.^[16][17]

2. The inner surface of the foreskin is fused with the glans penis. This is normal in children and adolescents but abnormal in adults.^[17]

3. The frenulum is too short to allow complete retraction of the foreskin (a condition called frenulum breve).^[17]

Pathological phimosis (as opposed to the natural non-retractability of the foreskin in childhood) is rare and the causes are varied. Some cases may arise from balanitis (inflammation of the glans penis),^[18] perhaps due in turn to inappropriate efforts to retract an infant's foreskin.
Beaugé noted that unusual masturbation practices, such as thrusting against the bed or rubbing the foreskin forward may cause phimosis. Patients are advised to stop exacerbating masturbation techniques and are encouraged to masturbate by moving the foreskin up and down so as to mimic more closely the action of sexual intercourse. After giving this advice Beaugé noted not once did he have to recommend circumcision.^[19][20]
Lichen sclerosus et atrophicus (thought to be the same condition as balanitis xerotica obliterans) is regarded as a common (or even the main)^[21] cause of pathological phimosis.^[22] This is a skin condition of unknown origin that causes a whitish ring of indurated tissue (a cicatrix) to form near the tip of the prepuce. This inelastic tissue prevents retraction.
Phimosis may occur after other types of chronic inflammation (such as balanoposthitis), repeated catheterization, or forcible foreskin retraction.^[23]
Phimosis may also arise in untreated diabetics due to the presence of glucose in their urine giving rise to infection in the foreskin.^[24]
Phimosis in older children and adults can vary in severity, with some able to retract their foreskin partially (relative phimosis), and some completely unable to retract their foreskin even when the penis is in the flaccid state (full phimosis).

Treatment

Physiologic phimosis, common in males 10 years of age and younger, is normal, and does not require intervention.^{[16] [25] [26]} Non-retractile foreskin usually becomes retractable during the course of puberty.^[26]
If phimosis in older children or adults is not causing acute and severe problems, nonsurgical measures may be effective. Choice of treatment is often determined by whether the patient (or doctor) views circumcision as an option of last resort to be avoided or as the preferred course.^{[citation needed]}

Nonsurgical

• Topical steroid creams such as betamethasone, mometasone furoate and cortisone are effective in treating phimosis and may provide an alternative to circumcision.^[25] It is theorized that the steroids work by reducing the body's inflammatory and immune responses, and also by thinning the skin.^[25]
• Stretching of the foreskin can be accomplished manually, with balloons^[27] or with other tools. Skin that is under tension expands by growing additional cells. A permanent increase in size occurs by gentle stretching over a period of time. The treatment is non-traumatic and non-destructive. Manual stretching may be carried out without the aid of a medical doctor. The tissue expansion promotes the growth of new skin cells to permanently expand the narrow preputial ring that prevents retraction.
• Beaugé treated several hundred adolescents with unusual masturbation habits and techniques, such as thrusting against the bed or rubbing the foreskin forward. He advised them to masturbate by lightly grasping the shaft of the penis and pulling it back and forth. Retraction of the foreskin was generally achieved after four weeks and he stated that he never had to refer one for surgery.^[19][20]

Surgical

Preputioplasty:
Fig 1. Penis with tight phimotic ring making it difficult to retract the foreskin.
Fig 2. Foreskin retracted under anaesthetic with the phimotic ring or stenosis constricting the shaft of the penis and creating a “waist”.
Fig 3. Incision closed laterally.
Fig 4. Penis with the loosened foreskin replaced over the glans.

Surgical methods range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness:

• Circumcision is sometimes performed for pathological phimosis, and is effective.
• Dorsal slit (superincision) is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue.
• Ventral slit (subterincision) is an incision along the lower length of the foreskin from the tip of the frenulum to the base of the glans, removing the frenulum in the process. Often used when frenulum breve occurs alongside the phimosis.
• Preputioplasty, in which a limited dorsal slit with transverse closure is made along the constricting band of skin^[28][29] can be an effective alternative to circumcision.^[13] It has the advantage of only limited pain and a short time of healing relative to circumcision, and avoids cosmetic effects.

While circumcision prevents phimosis, studies of the incidence of healthy infants circumcised for each prevented case of potential phimosis are inconsistent.^{[12][23][26][30][31][32]}

Prognosis

The most acute complication is paraphimosis. In this condition, the glans is swollen and painful, and the foreskin is immobilized by the swelling in a partially retracted position. The proximal penis is flaccid. Some studies found phimosis to be a risk factor for urinary retention^[33] and carcinoma of the penis.^[34]

Epidemiology

A number of medical reports of phimosis incidence have been published over the years. They vary widely because of the difficulties of distinguishing physiological phimosis (developmental nonretractility) from pathological phimosis, definitional differences, ascertainment problems, and the multiple additional influences on post-neonatal circumcision rates in cultures where most newborn males are circumcised. A commonly cited incidence statistic for pathological phimosis is 1% of uncircumcised males.^{[23][30],[12]} When phimosis is simply equated with nonretractility of the foreskin after age 3 years, considerably higher incidence rates have been reported.^[26][31] Others have described incidences in adolescents and adults as high as 50%, though it is likely that many cases of physiological phimosis or partial nonretractility were included.^[32]

History

According to some accounts, phimosis prevented Louis XVI of France from impregnating his wife for the first seven years of their marriage. She was 14 and he was 15 when they married in 1770. However, the presence and nature of his genital anomaly is not considered certain, and some scholars (such as Vincent Cronin and Simone Bertiere) assert that surgical repair would have been mentioned in the records of his medical treatments if it had indeed occurred.^{[citation needed]} It should be mentioned that non-retractile prepuce in adolescence is normal and common.^[26]
U.S. president James Garfield was assassinated by Charles Guiteau in 1881. Guiteau's autopsy report indicated that he had phimosis. At the time, this led to the simplistic speculation that Guiteau's murderous behavior was due to phimosis-induced insanity.
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